What is the billing behind OB?

[MetaPhysicianBlog]

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Howdy.

Anesthesia resident.

I'm looking to better understand the billing behind OB. I'm looking to pick up a few shifts as an attending after graduation in a few years. I won't be doing fellowship in it. Just something to supplement some income.

I've heard that OB can be lucrative. I'm not 'doing it for the money'. I get how 'if you wanted money don't go into medicine.'

1a. I imagine billing is q 15 mins once an epidural is in - right? So is this like running 10 anesthesia records at once?

1b. I imagine there is a discrepancy between private insurance and government insurance. How large of a difference is it for OB?

2. Is there a holy grail in terms of payment structure- ie more c/s, more epidural placements, longer epidurals running etc?

3. How does PP OB differ from academic OB (workflow, billing, cocktails, communication, rounding)?

4. What makes the shifts challenging for you (ie not so friendly nurses, higher medicolegal risk, more unpredictable schedule, business of the day/night etc)?

Just want to be better able to evaluate this idea from learning from people know more than I do.

 

[aneftp]

The holy grail or waterloo of ob anesthesia is payor mix.

If you are stuck with high Medicaid ob population you are F’d. We are talking about getting paid $75 and potentially getting stuck in a low volume ob hospital in house with epidural running and no other ob patients. Imagine getting paid $75 for 24 hour ob coverage. Yes. That does happen. Thus is reason why people ask for subsidies with low payor mix.

If you have greater than 50% private ob. You can make a lot.

You seem like a too young resident. Focus on the basics of anesthesia first. The billing is something you will have years to learn. And frankly unless you are doing eat what you kill (getting rarer and rarer). It’s pointless to explain ob anesthesia billing

 

[MetaPhysicianBlog]

The holy grail or waterloo of ob anesthesia is payor mix.

If you are stuck with high Medicaid ob population you are F’d. We are talking about getting paid $75 and potentially getting stuck in a low volume ob hospital in house with epidural running and no other ob patients. Imagine getting paid $75 for 24 hour ob coverage. Yes. That does happen. Thus is reason why people ask for subsidies with low payor mix.

If you have greater than 50% private ob. You can make a lot.

You seem like a too young resident. Focus on the basics of anesthesia first. The billing is something you will have years to learn. And frankly unless you are doing eat what you kill (getting rarer and rarer). It’s pointless to explain ob anesthesia billing

Thanks for the info.

Yes I am focusing on the basic of anesthesia. That is what anesthesia residency is for. A forum like this may give me insight into stuff not covered in residency.

I respectfully challenge that learning the basics of ob anesthesia billing is pointless.

So then I'll be a new grad and be taken advantage of? That doesn't seem ideal.

What's the harm in wanting to learn a little bit more from people who know more?

Either I care about these topics - or someone else knows more than I do and I am at a disadvantage.

 

[MetaPhysicianBlog]

1) if you’re talking about epidurals, you get base+time units. I forget how many base units an epidural is assigned but you traditionally get 1 time unit per 15 minutes. My PP caps total units at 12 so it doesn’t matter much how long labor continues after epidural is placed. We have a blended unit model so it doesn’t matter what type of insurance the patient has. If you weren’t compensated on blended unit then government insurance would pay less/unit than private insurance. All this doesn’t matter if you get salary or hourly rate, btw, as the entity paying you would take the unit based revenue.

2) as I said above, depends on how you’re paid.

3) my PP OB experience differs. The L&D at my main hospital is quiet but it’s busier in the other main site.

4) challenging if the patient is obese. Also hate getting called when I’m asleep but that’s the job.

Thanks for the reply.

I imagine it is becoming more common to get a salary or hour rate nowadays, right?

I'll really focus in on the obese patients during training and use u/s.

 

[pjl]

Thanks for the reply.

I imagine it is becoming more common to get a salary or hour rate nowadays, right?

I'll really focus in on the obese patients during training and use u/s.

Your settings are annoying for sending you a PM about your real questions. The only thing I will publicly say is:

Please focus on obese patients in residency WITHOUT u/s. It is just unnecessary in almost every single circumstance.

 

[GaseousClay]

IMO OB is way overcompensated for what it is. not being a hater obviously I'm reaping the benefits but just sayin.

 

[AdmiralChz]

Please focus on obese patients in residency WITHOUT u/s. It is just unnecessary in almost every single circumstance.

This. It’s great academic practice to use it but out in the community it’s very unlikely you’ll have an ultrasound up on your L&D for this unless you want to try the Transvag probe?

 

[deleted50478]

Point is that there are many ways for you to get “screwed.” If you take a job that pays you a salary or hourly wage, then the expectation is that you will bill more than you’re getting paid. That’s simply how economics work in order for the practice to stay in business. You may get paid well, but the billing coming from your work would have to be higher in order for the business to be sustainable. Conversely, if you have a productivity model, then it’s likely that your more experienced colleagues know the system and would position themselves to have more OB if that is most lucrative. You just have to know the economics of your employer to determine what works best for you.

Getting paid less than you bill is fair enough... to a point.

I can’t tell you what % defines getting screwed, but I suspect all AMCs and unequal private practices are above X%.

 

[aneftp]

IMO OB is way overcompensated for what it is. not being a hater obviously I'm reaping the benefits but just sayin.

The whole anesthesia reimbursement is stupid. Private vs Medicare rates vs even lower Medicaid rates

Surgeons and other specialties get roughly 60 cents on the dollar for Medicare patients vs private for same procedure.

Yet anesthesia gets 30 cents on the dollar for private vs Medicare.

But we all private OVERPAYS For anesthesia services. Especially ob.

My wife repeat elective c s asa 1. Skin to skin 29 minutes. The anesthesia bill (what was paid out) was $2100 (super Bill $3100). That’s insane amount of money for what amounts to around 45 total minutes work work (epidural plus room time)

Yet same Medicaid patient u be lucky to get $125.

Most of us would rather settle for $1000 for cs If we can get 60 cents on the dollar on Medicare meaning getting paid $600 for Medicare (rare to have Medicare ob) but we should at least get paid $500 for Medicaid ob patients.

But life just doesn’t work that way.

 

[deleted162650]

This. It’s great academic practice to use it but out in the community it’s very unlikely you’ll have an ultrasound up on your L&D for this unless you want to try the Transvag probe?

Every single LD unit in the country has an US with the large curvilinear on it which is the one you want.

 

[Mman]

Every single LD unit in the country has an US with the large curvilinear on it.

we certainly don't keep one L&D and we do thousands of labor epidurals every year

 

[kmurp]

Some of our insurance plans cap time units on labor epidurals.

 

[AdmiralChz]

we certainly don't keep one L&D and we do thousands of labor epidurals every year

He’s talking about the trans abdominal probe lolz

 

[Mikkel]

Never used ultrasound for an epidural, yet I still have easy success with the harpoon using seamarks.

 

[Ronin786]

we certainly don't keep one L&D and we do thousands of labor epidurals every year

You don't. The OB team definitely does.

 

[Impromptu]

Payment varies from state to state. Per a previous billing company, average epidurals in Illinois collected about $800-$900, Medicaid included. Whereas nearby Michigan collected $250/epidural, which included private insurers. I know that Illinois has a bad reputation for medical professionals, but they paid for epidurals well.

 

[ZzzPlz]

Never used ultrasound for an epidural, yet I still have easy success with the harpoon using seamarks.

 

[dchz]

Largest BMI for me was 65. The back fat formed a shelfing for me to put my items. kinda nice.

Tried to take a look with curvelinear probe... image kinda questionable and grainy. The markings i make moves too much because there is no anchoring. Didn't dare to ask to do it in plane with touhy needle so i just did it by stepping off the bone.

IME the hardest part is taping it so it doesn't get pulled... OP, be sure to let all the fat bounce back before you tape it.

 

[Mman]

You don't. The OB team definitely does.

that's true, but I've seen where that thing has been

 

[rakotomazoto]

OB anesthesia is tightly controlled in some groups. Some of my co residents were joining private groups where they had a lucrative OB setup that was only available to senior partners. Red flag. They will say, "rites of passage, you will earn access once you are a senior partner, too." Right or wrong, it definitely goes on.

In response to original question #3, in residency they expected us to pre op and consent every woman who was admitted to L&D. We had to change the epidural infusion when it ran out, we pulled the epidural catheters after delivery, once "given permission" to do so by the OB and RN's. That's right, on nights you would be paged at 3am with a request for a bag change or to pull a catheter for a woman who might have delivered hours ago and no one had bothered to call sooner.

There was a lot of tasks given to us in the name of "education" and due to the fact that we were the most disenfranchised and powerless provider on the team.

Private practice? None of the busywork. They call to request an epidural, I roll in and place it, put in the orders, and say, "call if there's any trouble". Callbacks and pages are very rare.

In regards to #4, some people have a visceral hate of OB for many reasons including the politics and very high female hormone levels of many L&D departments. All of the physiological changes of pregnancy can put us in challenging situations, too many to list here. Some places treat "anesthesia" poorly because we usually come and make a cameo appearance and then disappear for significant portions of time. The people that like it will say things like, "the patients are mostly young and healthy. It's usually easy money. Happiest place in the hospital, etc."

Like anything, OB can be a sweet gig or your worst nightmare, the details really do matter.

 

[MetaPhysicianBlog]

Your settings are annoying for sending you a PM about your real questions. The only thing I will publicly say is:

Please focus on obese patients in residency WITHOUT u/s. It is just unnecessary in almost every single circumstance.

Thanks for the response.

I've changed my inbox settings. Looking forward to hearing what you have to say.

Seems like the u/s statement is a bit controversial. What if one views it as a rescue technique? Meaning I would try to place an epidural without it but if I miss a few times then take it out and take a peek? Meaning it would be just another tool.

IMO OB is way overcompensated for what it is. not being a hater obviously I'm reaping the benefits but just sayin.

Interesting. Could you explain why?

The whole anesthesia reimbursement is stupid. Private vs Medicare rates vs even lower Medicaid rates

Surgeons and other specialties get roughly 60 cents on the dollar for Medicare patients vs private for same procedure.

Yet anesthesia gets 30 cents on the dollar for private vs Medicare.

But we all private OVERPAYS For anesthesia services. Especially ob.

My wife repeat elective c s asa 1. Skin to skin 29 minutes. The anesthesia bill (what was paid out) was $2100 (super Bill $3100). That’s insane amount of money for what amounts to around 45 total minutes work work (epidural plus room time)

Yet same Medicaid patient u be lucky to get $125.

Most of us would rather settle for $1000 for cs If we can get 60 cents on the dollar on Medicare meaning getting paid $600 for Medicare (rare to have Medicare ob) but we should at least get paid $500 for Medicaid ob patients.

But life just doesn’t work that way.

Thanks for the numbers. This really drives home the importance of payor mix.

Some of our insurance plans cap time units on labor epidurals.

Ah, so there is a cap. Bummer

Largest BMI for me was 65. The back fat formed a shelfing for me to put my items. kinda nice.

Tried to take a look with curvelinear probe... image kinda questionable and grainy. The markings i make moves too much because there is no anchoring. Didn't dare to ask to do it in plane with touhy needle so i just did it by stepping off the bone.

IME the hardest part is taping it so it doesn't get pulled... OP, be sure to let all the fat bounce back before you tape it.

This is perfect. Thanks.

OB anesthesia is tightly controlled in some groups. Some of my co residents were joining private groups where they had a lucrative OB setup that was only available to senior partners. Red flag. They will say, "rites of passage, you will earn access once you are a senior partner, too." Right or wrong, it definitely goes on.

In response to original question #3, in residency they expected us to pre op and consent every woman who was admitted to L&D. We had to change the epidural infusion when it ran out, we pulled the epidural catheters after delivery, once "given permission" to do so by the OB and RN's. That's right, on nights you would be paged at 3am with a request for a bag change or to pull a catheter for a woman who might have delivered hours ago and no one had bothered to call sooner.

There was a lot of tasks given to us in the name of "education" and due to the fact that we were the most disenfranchised and powerless provider on the team.

Private practice? None of the busywork. They call to request an epidural, I roll in and place it, put in the orders, and say, "call if there's any trouble". Callbacks and pages are very rare.

In regards to #4, some people have a visceral hate of OB for many reasons including the politics and very high female hormone levels of many L&D departments. All of the physiological changes of pregnancy can put us in challenging situations, too many to list here. Some places treat "anesthesia" poorly because we usually come and make a cameo appearance and then disappear for significant portions of time. The people that like it will say things like, "the patients are mostly young and healthy. It's usually easy money. Happiest place in the hospital, etc."

Like anything, OB can be a sweet gig or your worst nightmare, the details really do matter.

Good to know that PP doesn't have much of the busywork. I don't mind placing the epidural. It is the rounding on it every 2-3 hours, seeing patients post-ops, refilling bags, telling a G1 that her labor pain has changed and this is what we talked about during consent, and then trying to calm down the nurses.